经 TAVR 术前 CTA 检查对 TAVR 前严重 CAD 的筛查效果。
Effectiveness of Pre-TAVR CTA as a Screening Tool for Significant CAD Before TAVR.
机构信息
Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. Electronic address: https://twitter.com/npkondo.
Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
出版信息
JACC Cardiovasc Interv. 2023 Aug 28;16(16):1990-2000. doi: 10.1016/j.jcin.2023.05.030.
BACKGROUND
Computed tomography angiography (CTA) and invasive coronary angiography (ICA) are routinely performed before transcatheter aortic valve replacement (TAVR) to assess aortic root anatomy and screen for coronary artery disease (CAD), respectively.
OBJECTIVES
This study explored the efficacy of CTA as a screening tool for significant proximal CAD before TAVR.
METHODS
With proper ethical oversight, patients undergoing TAVR at Cleveland Clinic with a preprocedural CTA and invasive coronary angiography (ICA), and no prior percutaneous intervention, were identified from 2015 to 2021. Blinded to ICA results, the authors reviewed the left main, proximal left anterior descending coronary artery, proximal left circumflex coronary artery, and proximal right coronary artery by CTA coronary reconstruction to assess for nonsignificant stenosis (0% to 49%), moderate stenosis (50% to 69%), and severe stenosis (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen Kappa statistic were analyzed.
RESULTS
2,217 patients (53.4% male, age 79.2 ± 8.5 years) met inclusion criteria. CTA evaluation revealed a sensitivity of 90%, specificity of 92%, PPV of 74%, and NPV of 97% for detecting ≥50% stenosis. Using a ≥70% stenosis cutoff, evaluation revealed a sensitivity of 91%, specificity of 97%, PPV of 83%, and NPV of 99%. Assessment of bypass graft patency revealed a sensitivity of 86%, specificity of 97%, PPV of 84%, and NPV of 98%. Cohen Kappa analysis indicated substantial to near perfect agreement between pre-TAVR CTA and ICA.
CONCLUSIONS
Pre-TAVR CTA has a high NPV for high-grade proximal stenosis of each coronary artery. As a result, CTA can be used as a screening tool to rule out significant proximal CAD in patients undergoing TAVR.
背景
计算机断层扫描血管造影（CTA）和有创性冠状动脉造影（ICA）通常分别用于经导管主动脉瓣置换术（TAVR）之前评估主动脉根部解剖结构和筛查冠状动脉疾病（CAD）。
目的
本研究旨在探讨 CTA 作为 TAVR 前评估近端 CAD 严重程度的筛查工具的效果。
方法
在克利夫兰诊所，对 2015 年至 2021 年期间进行 TAVR 并具有术前 CTA 和有创性冠状动脉造影（ICA）但无先前经皮介入治疗的患者进行了识别。在不了解 ICA 结果的情况下，作者通过 CTA 冠状动脉重建评估左主干、近端左前降支冠状动脉、近端左回旋支冠状动脉和近端右冠状动脉，以评估非狭窄（0%至 49%）、中度狭窄（50%至 69%）和严重狭窄（≥70%）。分析了敏感性、特异性、阳性预测值（PPV）、阴性预测值（NPV）和 Cohen Kappa 统计量。
结果
2217 名患者（53.4%为男性，年龄 79.2±8.5 岁）符合纳入标准。CTA 评估显示，检测≥50%狭窄的敏感性为 90%，特异性为 92%，PPV 为 74%，NPV 为 97%。使用≥70%狭窄的截断值，评估显示敏感性为 91%，特异性为 97%，PPV 为 83%，NPV 为 99%。评估旁路移植血管通畅性显示敏感性为 86%，特异性为 97%，PPV 为 84%，NPV 为 98%。Cohen Kappa 分析表明，TAVR 前 CTA 与 ICA 之间存在高度一致到近乎完美的一致性。
结论
TAVR 前 CTA 对每个冠状动脉近端的高级别狭窄具有高阴性预测值。因此，CTA 可作为 TAVR 患者评估近端 CAD 的筛查工具。
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